Dr. Syed Zakir HossainAsso. Prof. of Medicine

Shaheed Syed Nazrul Islam Medical CollegeKishoreganj

Objectives

At completion of this presentation the audience will understand:

1. Adherence or Non-adherence to medication & co-morbidity

2. Present Global & Local status of Hypertension

3. Prevalence of Non-adherence effect to antihypertensive

4. How to Improve non-adherence: According WHO five dimension

5. Physicians Role for improving Adherence to antihypertensive

6. Recommendation

Adherence?

Cluster of behaviors

Simultaneously affected by multiple factors

The extent to which a person’ s behavior—taking

medication, following a diet, or making healthy lifestyle

changes—corresponds with agreed-upon recommendations

from a health-care provider. also called compliance.

World Health Organization, 2003

1. http://apps.who.int/iris/bitstream/10665/42682/1/9241545992.pdf

Persistence: The duration of treatment (ie, the

length of time a patient fills his/her prescriptions)

Non-adherence?

• Nonadherence with medication is a

complex and multidimensional health care

problem.

• Patient nonadherence can be a

pervasive threat to health and wellbeing

and carry an appreciable economic burden

as well. In some disease conditions, more

than 40% of patients sustain significant

risks by misunderstanding, forgetting, or

ignoring healthcare advice.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3711878/pdf/ppa-7-675.pdf

Global Medication Adherence is 50%

Nonadherence to Therapy:

A Major Challenge

• Nonadherence ( noncompliance, no persistence, etc.) is a

major problem

• Within 1 year, ~50% of patients overall discontinue use of

drugs

• An additional ~35% discontinue treatment within

2 years

National Council on Patient Information and Education, 1997. US

“Current methods of improving adherence for chronic health

problems are mostly complex and not very effective.”

Cochrane Database Systematic Review (2008)

Haynes RB et al

Cheng JWM et al. Pharmacotherapy. 2001;21:828-841.

Patient Reasons for

Nonadherence

4%

1%

1%

2%

3%

6%

7%

7%

14%

55%

Hate taking

Don’t like being dependent

Drugs give me side effects

Don’t think drugs are working

Too expensive

Don’t like being told what to take

Just forget

Other

Supply will last longer

Prospective, open-label, interview-based study in metropolitan New York area pharmacies (N=821).

Don’t think it’s necessary all the time

Global Prevalence of Hypertension

http://www.who.int/mediacentre/factsheets/fs310/en/index2.htm

http://www.world-heart-federation.org/cardiovascular-health/cardiovascular-disease-risk-factors/hypertension/

Hypertension is the leading risk factor for death and for disability globally

Global Leading Risks for Death

9.4 million deaths/year

Global Burden of Disease Study 2010 , Lancet 2012; 380: 2224–60

HYPERTENSION: Attributable Risk

• Only half of the burden seen in people with hypertension

(BP > 140 mmHg); remainder in prehypertensives (BP > 115mmHg)

• > 80% of the burden seen in low-income and middle-income regions

• Over half occurred in people aged 45-69 yrs

54% stroke

47% IHD

25% other CVD

13.5% Total mortality

Study by Int Society of hypertension; Lancet May 2008;371:1513-8

Global non-adherence to antihypertensive medication

Hypertension in Bangladesh

18%

OverallPrevalence

Age Group(both sexes)

% of hypertensive patients(BP > 140/90 mmHg)

25-34 yrs

35-44 yrs

45-54 yrs

55-64 yrs

65+ yrs

6.4%

15.2%

24%

33%

41%

Non-communicable disease risk factor survey, Bangladesh 2010

Urban > Rural

Hypertension Control in Bangladesh

HTN

24.4%

Under Treatment

41.2%

Not on

treatment

Undiagnosed

Diagnosed

50.1%

Controlled

31.4%

Uncontrolled

68.6%

7 out of 10 hypertensive patients

are having uncontrolled hypertension.

Journal of Hypertension, Issue 33, Volume 3, March 2015, p 465-472

Hypertension: adherence to treatment in rural Bangladesh findings from a population based study

• The study population included 29,960 men and women

aged 25 years and older

• The prevalence of hypertension was 13.67%.

• Qualified providers diagnosed only 53.5%

• the unqualified providers, village doctors diagnosed 40.7%.

• 26% discontinued the use of medication.

• Non-adherence was 52 % greater when hypertension was

diagnosed by unqualified providers.

ISSN: 1654-9716 (Print) 1654-9880 (Online) Journal homepage: 2014 Masuma Akter Khanam et al. http://www.tandfonline.com/loi/zgha20

Prevalence of Non-adherence effect to

antihypertensive• Patients with cardiovascular comorbidity were also less likely to be

non-adherent to antihypertensive medication.

• For years, emphasis has been placed on the problem of medication

non-adherence

– $290 billion a year in direct and indirect costs = 13% of total health

care spend

– 125,000 deaths that result from not taking medication correctly

– 69% of medication-related hospital admissions due to poor

adherence

– 50% of new statin patients will discontinue medication after 6

months

NEHI. Thinking Outside the Pillbox: A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease. 2009World Health Organization. Adherence to long-term therapies: Evidence for action. 2003Benner JS, Glynn RJ, Mogun H. Long-term Persistence in Use of Statin Therapy in Elderly Patients. JAMA. 2002;288(4):455-461

Study on Adherence when Patients are

well aware about hypertension

• Dropouts from BP Treatment Hard to Find in

Population Studies

Harris poll

91% of aware hypertensives on medication Moser M, J Clin Hypertension 2007

NHANES 2003-2004

94% of persons who ever took any BP med still take

one Houston Population Survey

When Non-adherence to antihypertensive

• Non-adherence to antihypertensive increased relative risk

for mortality (~12% to 25%)

• Non-adherence to cardio protective medications increased

risk of cardiovascular hospitalizations (10% to 40%) and

mortality.

• For elderly patient-

Approximately 7.1 million die of complications of

uncontrolled hypertension

» Adherence rates in the elderly vary from 26% to 59%

Sources: Ho 2009, Circulation; Edmondson 2013, Br J of Health Psychology;

Michaela Jones, AGPCNP-BC, is a DNP candidate at Columbia University

Improve non-adherence: According

WHO five dimension• WHO’s Five Interacting Dimensions of Non-

Adherence

http://apps.who.int/iris/bitstream/10665/42682/1/9241545992.pdf

• 1. Economical & social factors

Low Socioeconomic status

Poverty

Illiteracy

Low level of education

Unemployment

Medication cost Source

http://apps.who.int/iris/bitstream/10665/42682/1/9241545992.pdf

Belief about illness &

treatment

Organizational variables

Race

Age

Lack of family or social

support

Unstable living conditions

• 2. Health-care team & system related factors

Good patient- provider

relationship

Poorly developed health

services

Poor medication

distribution system

Lack of knowledge and

training for health care

provider on managing

chronic diseases

http://apps.who.int/iris/bitstream/10665/42682/1/9241545992.pdf

Overwork health-care providers

Lack of incentives & feedback

on performance

Short consultation time

Weak capacity of the system to

educate the patients

• 3. Condition Related

Chronic conditions such as hypertension, that lack symptoms highly impact the level of adherence Rate of progression & severity of

the disease Availability of effective treatment patient’s risk perception ability Co-morbidities improve the

adherence behavior

http://apps.who.int/iris/bitstream/10665/42682/1/9241545992.pdf

4. Therapy Related

Complexity of medication

Unpleasant side effects.

Frequent changes in regimen

Previous treatment failure

Duration of therapy

Dosing several times a day may contribute to non-adherence.

Lack of immediate benefit of therapy

1. http://apps.who.int/iris/bitstream/10665/42682/1/9241545992.pdf

Therapy Provider/ Doctors Factors –

Communication skills

Knowledge of health literacy issues

Lack of empathy

Lack of positive reinforcement

Number of comorbid conditions

Number of medications needed per day

Types or components of medication

Amount of prescribed medications or

duration of prescription

Cont.…..

1. Source: Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X. Interventions for enhancing medication adherence. Cochrane Database Syst Rev 2008;(2):CD000011

• 5. Patient Related

Patient’s knowledge & beliefs about their illness

Patient’s understanding about the consequences of poor adherence

Forgetfulness

Psychological stress

Feeling stigmatized by disease

Anxiety about possible adverse effects low motivation Lack of self perceived need for treatmentNegative believe regarding the efficacy of the treatment Low attendance in follow-up visit

Monane M et al. Am J Hypertens. 1997;10:697-704.

More Frequent Physician Visits

Improved Adherence

0.80

1.00

1.20

1.40

1.60

1.80

2.00

2.20

2.40

2.60

1-3 4-7 8+

Physician visits in last 120 days

Ad

he

ren

ce ≥

80

% (

OR

)

Retrospective study of elderly (aged 65 to 99 years) members of the New

Jersey Medicaid and Medicare populations (N=8643).

Physicians Role for improving Adherence to

antihypertensive

• Improved adherence can lead to:

– Higher rates of treatment success

– Fewer diagnostic procedures

– Fewer hospitalizations

– Lower mortality rates

Benner JS et al. JAMA. 2002;288:255-261.

Insull W. J Intern Med. 1997;241:317-325.

World Health Organization. World Health Organization; Geneva, Switzerland. 2003.

What May Providers Do to

Overcome These Challenges?

Communication is key!

Effective interventions

Measure medication adherence

Ratanawongsa 2012 Arch Intern Med ; Bramley 2006 J Manag Care Pharm 12(3):239-245;

INTERVENTIONS-

• SIMPLE

• S— Simplify the regimen

• I — Impart knowledge

• M—Modify patient beliefs and behavior

• P —Provide communication and trust

• L —Leave the bias

• E —Evaluate adherence

Measure medication adherence

Interventions of medication Should be Patient-Tailored - Behavior-related

Forgetfulness of patients

- Daily alerts

- 90 days medication supplies

- Automatic renewals

Clinical—Questions or concerns about medication

Pharmacist consultation

Linguistically and culturally appropriate

Cost-related

Payment assistance programs

Lower cost medication alternatives

Lower cost pharmacy option (e.g. , home delivery)

Effective Strategies for Improving Hypertension

Medication Adherence-

Team-based care

Pharmacist-led multicomponent interventions

Education with behavioral support

Pill counting

Blister packaging

Electronic monitoring

Telecommunication systems for monitoring and counseling

Single dose vs. multiple dose prescribed

1. Sources: Walsh J, McDonald K, Shojania K, et al. Quality improvement strategies for hypertension management: a systematic review. Medical Care 2006;44:646-57; Viswanathan M,

Golin CE, Jones CD, Ashok M, Blalock SJ, Wines RC, et al. Interventions to improve adherence to self-administered medications for chronic diseases in the United States: a systematic

review. Ann Intern Med 2012; 157(11):785-795.

How to Overcome Challenges or Barriers by System Change

Introduce team-based care

- Collaborate with pharmacists and/or nurses

- Educate patients on how to take medications

- Monitor by pill box

Improve access and communication

- Offer patients the opportunity to contact the provider’s office with any questions

- Use telemedicine, particularly in rural areas

Use technologies and analytical services that facilitate measuring and

improved adherence

Last but not the least-

Script Your Future -National multiyear campaign to raise awareness about medication

adherence

This campaign brings together stakeholders in health care, business,

and government .

For health-care professionals, the campaign offers guidance on how to

improve communication with patients

For patients, the campaign offers practical tools to improve medication

adherence

http://scriptyourfuture.org/wp-content/themes/cons/m/release.pdf

US Surgeon General Regina Benjamin, MD

(2009-2013)―Doctors, nurses, pharmacists and other health care

professionals can help prevent many serious health

complications by initiating conversations with their

patients about the importance of taking medication as

directed. This is especially important for people with

chronic health conditions such as diabetes, asthma and

high blood pressure, who may have a number of

medicines to take each day.‖

Regina M. Benjamin

http://scriptyourfuture.org/wp-content/themes/cons/m/release.pdf

Take-Home Messages

Take-Home Messages for Providers / Doctors-

Display patience and empathy when interacting with patients

Be mindful of the number of medications prescribed and their frequency

and dosages.

Prescribe lower-cost medications and/or provide manufacturer coupons to

help lower costs.

Explain the consequences of non-adherence and suggest ways to

improve adherence.

Introduce team-based care to improve medication adherence

Identify roles and responsibilities in team-based care to deliver improved

patient-centered health care

Need to develop a Hypertension guideline of ours for patient benefit

oriented.

Thank You